CRITICAL CARE

NURSING CLINICS
OF NORTH AMERICA

ELSEVIER
SAUNDERS

Crit Care Nurs Clin N Am 16 (2004) 6173

Prehospital and emergency department burn care

Scott DeBoer, RN a,b'*, Annemarie O'Connor, RN e
'Peds-R-Us Medical Education, P.O. Box 601, Dyer, IN 46311, USA
bClassic LifeGuard, P.O. Box 7200, Page, AZ 86040, USA
'University of Chicago Burn Center, 5841 South Maryland Avenue, Chicago, IL 60637, USA

If all that changes slowly is explained by life

All that changes quickly is explained by fire!
G. Bachelard (18841962)

When paramedics and emergency department

nurses are asked what kind of patients they most fear
caring for, the answer typically involves critically ill
children and burn victims. No one wants to think about
a child, or even an adult, being subjected to pain,
multiple debridements and surgeries for grafting, and
physical and emotional scars associated with burn
injuries that may last a lifetime. Bum-injured patients
have special needs in the prehospital and emergency
department settings. This article addresses the nursing
priorities in prehospital and emergency department
care.

Skin anatomy
A brief review of skin anatomy provides concepts
necessary to understand emergency burn assessment
findings and later treatment strategies. The epidermis is
the outermost layer of skin; under the epidermis are the
dermis, subcutaneous tissue, muscle, and bone;
throughout the epidermis and dermis are pain
receptors. Infants, young children, and elderly adults

* Corresponding author. Peds-R-Us Medical Education,

P.O. Box 601, Dyer, IN 46311. E-mail address:
scott@Peds-R-Us.com (S. DeBoer).

have a much thinner dermal layer with a resulting

greater propensity for deeper burns. The skin provides
several important functions, but four essential functions that apply to emergency burn care are protection
against infection, prevention of fluid loss, temperature
maintenance, and sensation (eg, pain perception) [13].
Fig. 1 provides a schematic view of the skin and depth
of burn injuries.

Degree of burn versus burn thickness

Burns have been historically classified as first
degree, second degree, or third degree by prehospital
emergency medical services (EMS) and emergency
department personnel. More recently, especially in
burn centers, the depth of the burn is described as being
partial or full-thickness; however, most EMS and
emergency department staff still use the first- to thirddegree classification, probably because they infrequently encounter critically ill burn patients. Firstdegree (superficial) burns are most commonly seen
with sunburns and brief heat exposures. They are red,
exquisitely painful, and involve only the epidermis.
Patients with extensive first-degree burns may need
narcotic analgesia and mild fluid resuscitation, but
these burns are rarely life threatening and do not
require debridement or grafting [1,2]. Second-degree (
partial-thickness) burns are classified as either being
superficial or deep partial-thickness. Superficial partial-thickness burns involve the epidermis and the
superficial dermis. Blistering of the skin is commonly
seen either on initial presentation or several hours later,
along with severe pain. Deep partial-thickness

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S. DeBoer, A. O'Connor / Crit Care Nurs Clin N Am 16 (2004) 6173

62

Stratum corneum
Stratum lucidum
ID Stratum granulosum
_"a
Stratum spinosum
Stratum basale
Partial
Hair follicle
thickness -cc
Sweat gland
N
Nerve

Full
thickness

Fig. I. Layers of the skin involved in burn injury. From Ogden B. Nursing management of adults with burns. In: Beare P,
Myers J, editors. Principles and practice of adult health nursing. 2nd edition. St. Louis (MO): Mosby; 1994. p. 2119; with
permission.

burns are deeper than superficial partial-thickness burns,

resulting in more destruction of the dermal layer. A
clinical guide to differentiating between partial and fullthickness bums is the presence of pain at the bum site in
partial-thickness bums and the absence of pain in fullthickness bums. It is important to remember that the
severity of a bum may not be apparent for 24 to 48 hours.
An injury that may initially present as a partial-thickness
bum may extend into a full-thickness bum. Also, burn
patterns are frequently mixed, so it may be difficult to
differentiate clearly between a partial-thickness wound
and a full-thickness injury [1,2]. Third-degree (fullthickness) bums involve the epidermis, dermis, and
possibly subcutaneous tissue. In appearance, full-thickness
bums can be black, brown, or white, and leathery, dry, or
charred. Third-degree bums may not be painful because
the pain receptors have been destroyed. A clinical caveat is
that third-degree bums commonly occur in a bull's-eye
pattern with third-degree burns surrounded by seconddegree injury, so the patient will have areas that are
painful and other areas that are insensate. These more
superficial bum areas are the ones that can cause intense
pain for the patient [1,2]. There is some disagreement
about the use of the term "fourth-degree burn." Fourthdegree bums can be classified as deep full-thickness bums.
Most references agree that a fourth-degree injury involves
all skin layers, subcuta-

neous tissue, muscle, and possibly bone. These burns

commonly result in a nonviable extremity or, if very
extensive, in patient mortality [1,2].

EMS and emergency department assessment

overview
What makes a not-bad bum bad and a bad bum
really bad?

Several factors can negatively affect a bum patient's

prognosis. One factor is associated trauma, but the most
important factor is the patient's health status before the
bum injury. Coexisting medical conditions such as
diabetes, chronic obstructive pulmonary disease, asthma,
and cardiac disease, among others, are the primary reasons
for poor patient out-comes following burn injury.
Comorbidities increase the risk of complications such as
pneumonia, sepsis, multisystem organ dysfunction, and
poor healing [1,2]. Box 1 presents the American Bum
Association (ABA) criteria for bum center transfer and
referral. The ABA recommends transfer to a bum center
for significant thermal, electrical, or chemical bums as
well as for a "burn injury in patients with pre-existing
medical disorders which could complicate management,
prolong recovery, or affect mortality" [1,4].

S. DeBoer, A. O'Connor / Crit Care Nurs Clin N Am 16 (2004) 6173

Box 1. American Burn Association criteria

for major burn injuries [1,4]
Any patient with partial-thickness
burns greater than 10% total body
surface area
Any patient with burns that involve the
face, hands, feet, genitalia, perineum,
or major joints
Any patient with third-degree burns
Any patient with electrical burns,
including lightning injury
Any patient with chemical burns
Any patient with inhalation injury
Burn injury in patients with pre-existing medical disorders that could
complicate management, prolong recovery, or affect mortality
Any patient with burns and concomitant trauma in which the burn injury
poses the greatest risk
Burned children in hospitals without
qualified personnel or equipment for
their care
Any patient with burns who requires
special social, emotional, or long-term
rehabilitative intervention

For prehospital caregivers, the first priority, even

before assessing and managing any patient, is always
scene safety. Burn injury may involve trauma such as
that resulting from an explosion or fall. It is important
to discover from the patient or family members and onscene EMS personnel the mechanism of injury
involved. Questions to ask that may assist in assessing
mechanism of injury and presence of potential or
associated injuries are
Where was the patient found (eg, in bed versus
at the foot of the stairs)?
Was an explosion involved?
Did the victim jump from a window to avoid
the fire?
Asking questions that can shed light on other
potential or actual associated injuries is important in
early bum patient management [2]. Trauma patients
with bums are exactly that, trauma patients first and
foremost. They should be evaluated for life-threatening
injuries first at an emergency department or trauma
center as protocols and facilities allow. Once traumatic
injuries requiring immediate treat

63

ment (eg, spinal cord injury, epidural hematoma, ruptured spleen) have been ruled out, the focus should be
on the management of the burn injury [5]. Health care
workers instinctively want to address the bums first
because burn injuries are so dramatic in appearance,
and the patients are appropriately very vocal about
their bum pain. In the first few hours after injury,
however, the bum tissue injury is not usually lethal,
and emergent care involves correcting airway
compromise and providing fluid resuscitation. Fig. 2
demonstrates the time of exposure required for tissue
destruction at a known temperature. The higher the
temperature and longer the duration of expo-sure, the
greater the tissue damage [6]. Priorities for EMS,
however, are the immediate treatment of associated
traumatic injuries and airway and fluid resuscitation
management.
Last, a comparison of the alleged mechanism of
injury with the injury itself is essential when the
possibility of abuse, intentional injury, or even suicide
is being considered [1,7]. Box 2 presents assessment
findings that may suggest the health care team should
investigate more closely for possible intentional
injury.
Where is the patient burned? Inhalation injuries
Patients can be burned in one of two areas
internally and externally. An internal bum injury involves an inhalation injury or bums to the upper
airway. Emergency personnel should remember that a
patient who is burned on the outside is probably
burned on the inside. More importantly, a patient who
is swollen on the outside is probably is swollen on the
inside. This consideration is crucial with regards to
airway management: especially in children, who have
proportionately smaller airways, a little edema significantly compromises the airway (Fig. 3) [1]. Establishing and maintaining a patent airway is a primary
function of both the EMS and emergency department
personnel in any bum victim. Airway tissue edema
from the heat injury and chemical bums, compounded
by the intravenous (IV) fluids required for resuscitation, can quickly lead to airway compromise. Edema is
an equal opportunity killer [2]. Thus establishing and
maintaining an airway for bum-injured patients is a
life-saving procedure.
For a victim of a house fire, anxiety, fear, and
hypoxia all lead to tachypneic breathing of inhaled
smoke with carbon monoxide and the various other
toxic gases that accompany the superheated temperatures. Carbon monoxide poisoning should be presumed to be present in all thermal-bum patients when
smoke inhalation is involved. One hundred

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S. DeBoer, A. O'Connor / Crit Care Nurs Clin N Am 16 (2004) 6173

Fig. 2. Temperature duration curve. From Flynn M. Burn injuries. In: McQuillan K, VonRueden K, Hartsock R, Flynn M, Whalen
E, editors. Trauma nursing: from resuscitation through rehabilitation. 3rd edition. Philadelphia: WB Saunders; 2002. p. 788809;
with permission.

percent oxygen should be given until venous or

arterial carbon monoxide levels have been determined. Pulse oximetry is useful but can be misleading
when smoke inhalation is involved. Carbon monoxide
has 250 times more affinity for hemoglobin than does
oxygen. Most pulse oximeters cannot differentiate
between a hemoglobin molecule that is bound by
oxygen or carbon monoxide. Although an oxygen
saturation reading of 100% is normally a reassuring
reading, the pulse oximetry reading cannot be considered accurate unless the carbon monoxide level is
known. The actual oxygen saturation is derived by
subtracting the carbon monoxide level from the pulse
oximeter saturation. As an example, a pulse oximetry
reading of 100% with a carbon monoxide level of
50% means that the patient's actual oxygen saturation
is only 50%. Symptoms of carbon monoxide toxicity
are variable and nonspecific, ranging from headache
and nausea to coma and death. The classic symptom
of cherry-red coloration of the skin and mucous
membranes is inconsistently found, and its presence
or absence should not be considered diagnostic. Management remains controversial, with administration of
100% oxygen by facemask or endotracheal tube
continuing to be standard treatment, with hyperbaric
oxygen therapy as an additional possible therapy [2,5,
8,9]. With any burn-injured patient, the possibility of
airway involvement is a primary consideration

that must be assessed. Box 3 outlines commonly

encountered signs and symptoms that would lead one
to suspect an inhalation injury.
Where is the patient burned? Exterior injuries
How badly is the patient burned?
Prehospital and emergency department personnel
see three kinds of bum patients: (1) patients who can
be sent home; (2) bum patients who can be appropriately treated as an inpatient in a community hospital
setting (an option that should be used only if all those
involved in the care of the patient have the skills and

Box 2. Suspicious burns [3]

Any burn involving a child
History of tap water immersion
Multiple burns of same or different
ages
Presence or absence of splash marks,
spared regions, bilateral symmetry (
stocking/glove distribution)
Burns on the soles of the feet
Nonburn-associated trauma

S. DeBoer, A. O'Connor / Crit Care Nurs Clin N Am 16 (2004) 6173

NORMAL

65

EDEMA RESISTANCE X-SECT

AREA
1mm

INFANT

+ 1x

+75%

ADULT

+ 3x

344%

Fig. 3. Airway diameter/edema. From Wheeler M, Cole C, Todres I. Pediatric airway. In: Cote C, Todres 1, Ryan J, Goudsouzian N,
editors. A practice of anesthesia for infants and children. 3"i edition. Philadelphia: WB Saunders; 2001. p. 85; with permission.

experience needed to provide the required assessments and interventions); and (3) burn patients who
should be transferred for treatment in a burn center.
The ABA has established criteria that should be used
to determine admission versus transfer to a burn center (see Box 1). The University of Chicago Bum Center and the University of Chicago Aeromedical
Network (UCAN Transport Team) actively urge paramedics and emergency departments to use the "call
before they hit the door" protocol. The EMS providers
inform the emergency department that they will be
receiving a severely burned patient in "x" minutes and
asks the emergency department to contact the burn
center even before the patient arrives. This initial
notification of a possible burn admission or transfer
serves to determine burn center bed availability and
transport team readiness and allows the burn center to
assist with the initial telephone resuscitation guidelines and burn treatment suggestions given to the EMS
personnel in the field.
Regardless of the patient disposition, calculating
the percentage of burn is crucial for proper assess-

Box 3. Signs of inhalation injury [2]

Singed eyebrows or nasal hairs

Black nasal or oral discharge
Grossly swollen lips
Hoarse voice
Carbonaceous oropharynx or sputum
Facial burns
Abnormal oxygenation
History of enclosure in a smoke-filled
location

ment of severity of injury and subsequent treatments.

The most commonly used prehospital and emergency
tool used to assess the extent of burn tissue injury is the
Rule of 9s. To understand this rule, the mnemonic of "
little parts and big parts" is helpful. "Little parts"
represent 9% of total body surface area (TBSA), and "
big parts" represent 18% (Box 4). Children have a
critical
anatomic
difference:
the
head
is
disproportionately bigger than the body (Fig. 4).
Remembering that children have "big heads" is crucial,
because it makes a difference in calculating bum
percentage, evaluating heat loss, and determining
proper positioning if a spinal injury is suspected. When
calculating percentage of bums in pediatric patients,
the head is a "big part" and therefore represents 18% of
the TBSA, not 9% as in with adults.

Box 4. Real-life reminders for the Rule of

9s [1]
The body is divided into big parts and
little parts:
Big parts represent 18% of total
body surface area
Little parts represent 9% of total
body surface area (hence the Rule
of 9s)
Remember children have
Big head, little body syndrome: the
head is a big part (18% TBSA, not
9% as in adults)
Short and stubby leg syndrome:
legs in children represent 14%
TBSA (not 18% as in adults)

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S. DeBoer, A. O'Connor / Crit Care Nurs Clin N Am 16 (2004) 6173

ADULT
Fig. 4. Rule of 9s from infants to adults. From Syzfelbein S, Martyn J, Sheridan R, Cote C. Anesthesia for children with burn
injuries. In: Cote C, Todres I, Ryan J, Goudsouzian N, editors. A practice of anesthesia for infants and children. 3rd edition.
Philadelphia: WB Saunders; 2001. p. 52243; with permission.

Some guides as to bum severity note that children

have short, stubby legs that should be calculated as
14% of TBSA, not 18% as with adults [1,8]. For
prehospital and emergency department personnel who
do not treat extensive bums every day, however, the
simpler "big parts/little parts" mnemonic can be easier
to remember during these stressful situations.
Once a bum patient is stabilized, the Lund-Browder chart is frequently used and is more accurate than
the Rule of 9s, which can overestimate burn severity [
1,2]. Although the Rule of 9s is used for extensive
burns, the whole-hand equivalent may be used to
assess patchy bums (eg, a burn to the elbow rather
than to the entire arm). Until recently, the palm was
considered to be 1% of the TBSA. Studies have now
shown that the palm without digits is only 0.4% to 0.
5% TBSA; however, when the fingers are included in
the measurement, the hand represents 0.7% to 0.8%
TBSA (simplified as 1%) [10]. In summary, a bum to
the entire arm is a "little part" and therefore
approximately 9% TBSA; however a burn only to the
elbow is about the size of a patient's whole hand and
consequently only 1% TBSA.
ECG monitoring

ECG monitoring is appropriate for serious thermal

and all electrical burns, but the placement of ECG
leads may be difficult when there are extensively

burned areas [2]. ECG leads do not adhere to burned

tissues, so the leads must be placed in nontraditional
areas (eg, anywhere not burned, such as the back or
legs). If there are no unburned areas of the body, in the
prehospital setting, ECG leads can be placed in the
customary positions and held in place with a wrap of
gauze around the chest. In the emergency department
and burn center settings, a more invasive technique,
such as stapling ECG leads in place, may be used.
Appropriate systemic analgesics should be administered before this procedure. In thermally injured
patients, arrhythmias are most commonly related to
stress, hypovolemia, and acidosis. With electrical
injury victims, ventricular arrhythmias such as fibrillation can occur, and ECG monitoring should continue
for at least 24 hours after the injury [2].
Overview of EMS and emergency department
management

With any significant bum injury, all clothing and

jewelry should be removed, preferably by the EMS
personnel, before the patient arrives at the emergency
department. The early removal of jewelry avoids the
need for cutting it off later. Jewelry removal is a priority
because it is typically made of metal, which can retain
heat and continue to cause thermal damage and because
it may become a tourniquet as the surrounding tissues
become edematous. All jewelry

S. DeBoer, A. O'Connor / Crit Care Nurs Clin N Am 16 (2004) 6173

must be removed quickly even from unburned areas,

because patients can later exhibit enormous amounts of
generalized swelling. Burned clothing should be wet to
extinguish heat and then removed if possible by EMS
personnel. In the emergency department, remaining
clothing should be removed, and appropriate dressings
should be placed on the burned areas. Clothing that
adheres to the burn should be left in place. When the burn
is later debrided, any remaining clothing will be removed
with the burned tissue [11]. Special considerations to
prevent hypothermia must be addressed when the patient's
clothing is removed.

Airway, breathing, and circulation

Airway, breathing, and circulation (the ABCs) are the

basis of all emergency algorithms, and bums are no
different. Airway compromise caused by edema is
secondary to the effects of breathing superheated air or an
inhalation injury. Not all burn patients must be intubated.
A conscious patient with no respiratory distress, normal
oxygenation by arterial blood gases, and no visible airway
injury is highly unlikely to require urgent intubation.
When there are concerns about airway edema, patients,
especially children, should be intubated soon after arrival,
before the air-way is compromised by edema [2]. How
long does it take an airway to swell, and how much will it
swell? The answers to these two questions are unknown.
Think about what happens when a finger is slammed in a
car door. It swells immediately but continues to swell for
hours after the injury. The same process occurs with a
burned airway. An initial management principle for
potential airway compromise is that it is better to intubate
and secure an airway early, because it may not be possible
to secure the airway later as edema develops. Invasive
airways, such as needle or surgical cricothyroidotomy can
be done, but these techniques are challenging in most
patients and are significantly more difficult to perform in
children [12].
The decision to intubate the patient at the scene
depends on EMS protocols and assessment of the burn
victim. If the patient is unconscious or in an arrest state,
paramedics should immediately intubate the patient. If the
patient is unconscious but still has a gag reflex or remains
conscious even with severe facial burns, intubation in the
EMS environment using rapid sequence intubation (RSI)
techniques should be considered. If RSI is not an option,
then 100% oxygen should be administered by facemask
until the airway is definitively secured in the emergency
department [1,2,111. Last, once an endotracheal tube (
ETT) has been placed, securing placement can

67

be quite difficult in patients with severe facial bums.

Traditional methods of taping ETTs simply do not work;
therefore, use of either umbilical or twill tape or a
commercially prepared ETT fixation device should be
considered [1].
RSI using adequate sedation and analgesia and shortacting neuromuscular blocking agents (NMBA) has
become the airway management technique of choice in
the emergency department and operating room arenas.
Succinylcholine (Anectine) is a fast-acting agent (3060
seconds) with a short duration (810 minutes in most
patients) and is commonly used with RSI [13]. Although
the problem is unlikely arise in the initial few hours after
the burn (eg, in the EMS or emergency department
settings), succinylcholine should still be used with
extreme caution because severe hyperkalemia may result [
13]. Dr. Madelyn Kahana from the University of Chicago
Hospitals departments of pediatric critical care and
anesthesia teaches the "1 dayto1 year rule" regarding
succinylcholine and burns: "Succinylcholine is safe on the
day of the bum and 1 year after the burn, but never
between the two" [13]. This rule is needed to avoid
unnecessary life-threatening complications that may result
from hyperkalemia. Longer-acting NMBAs, such as
vecuronium (Norcuron), pancuronium (Pavulon ),
rocuronium (Zemuron), and cisatracrium (Nimbex) may
be used to assist with intubation or for muscle relaxation
after
intubation has been
successfully
accomplished.
Although
these
nondepolarizing NMBA do not cause the hyperkalemia
associated with succinylcholine, the duration of these
medications (2060 minutes) can be worrisome if they
are used to aid in intubation, especially if intubation
cannot immediately performed [13]. The practitioner must
remember that NMBAs do not pro-vide analgesia or
sedation. Their administration must be accompanied by
adequate amounts of IV sedatives and analgesics [13]. Dr.
Kahana frequently poses the following questions to
surgical residents and to emergency department, critical
care, and transport nurses:
1. How can you tell if the patient is sedated enough?
Vital signs are not a reliable indicator, especially
for patients in shock; NMBAs make the patient lie
still and not voice concerns, but if unless
concurrently sedated, the patient is awake and able
to hear and feel everything.
2. Why are you using NMBAs with the patient in the
first place? If the answer is because the patient is
moving or agitated, the patient is not sedated
adequately. If you give the patient enough sedatives
and analgesics, he will act as though he has
received a NMBA.

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S. DeBoer, A. O'Connor / Crit Care Nurs Clin N Am 16 (2004) 6173

Neuromuscular blocking agents do have a role

with intubation, surgical procedures, and with difficulties with ventilation, but in many cases liberal
doses of sedatives and analgesics can achieve the
same effect.
Intravenous fluids
IV fluids are administered to re-establish intravascular volume that was lost as a result of tissue
destruction from the bum and fluid shifts associated
with tissue edema. Establishing and securing an IV
line can be challenging. Nonburned areas and large
veins are the IV sites of choice. If there is unburned
area, an IV line can be placed in burned tissue. If
peripheral IV access cannot be quickly obtained, an
intraosseous line may be placed in children and adults
even if this area is burned. The tibia should be used in
children; in adults, the sternum (F.A.S.T.1 (Pyng
Technologies, Richmond, B.C., Canada), tibia, or arm
(Bone Injection Gun, WaisMed, Caesarea, Israel) may
be used for intraosseous cannulation [1,2].
Two common concerns are involved in the placement of an IV line through a burned area. The first
concern is securing an IV line placed in bum tissue.
For prehospital caregivers, wrapping the IV site snugly
with gauze will hold the line in place temporarily; as
with ECG leads, tape does not stick to burned tissue.
Once the patient arrives in the emergency department,
the IV line may be sutured with one or two simple
sutures. The second concern is the risk of infection.
IV lines should not be placed in a burned area, unless
there is no alternative, because infection is always an
issue; the rapid administration of fluid is of overriding importance, however [1,2].
Lactated Ringers (LR) or normal saline (0.9 NS)
solution may be administered depending on burn center preference and protocols. Both are both isotonic
fluids that allow maximum fluid to remain in the
intravascular space and re-establish perfusion. In
addition to resuscitation fluids, children should also
receive maintenance fluids containing dextrose, such
as D5LR, to avoid hypoglycemia. The consensus
formula, formerly known as the Parkland formula, is
commonly used as a guideline for initial fluid resuscitation. Fluid resuscitation formulas are only guides.
Other assessment parameters such as hemodynamic
status, acid base balance, and urine output should be
evaluated for each patient. Some patients need more
volume replacement than the formula recommends,
and certainly some patients need less. The consensus
formula calculates the amount of fluid to be given in
the first 24 hours after the burn, not after arrival for
treatment [11]. Most fluid loss occurs in the first

8 hours postburn, so half the total amount should be

administered in the first 8 hours after the bum in an
effort to re-establish tissue perfusion quickly. Box 5
summarizes the consensus formula.
An easy way to remember the components of this
formula is the following: 4 cc's x "big kid or a little
kid" ("big kids," ie, adults, get more fluids than "little
kids") x "bad burn versus not bad bum" ("bad bums"
get more fluid than "not bad" bums). For example,
based on the consensus formula, a healthy 100-kg,
20-year-old patient with a 50% TBSA burn would
receive 20,000 cc's in 24 hours; 10,000 cc's, or 10 L
of fluids, would be administered in the first 8 hours
after the bum. It can be challenging for paramedics
to use the consensus formula because in the EMS
arena, weight, and percent of TBSA burned are only
estimated. In addition, IV infusion pumps are not
commonly available in the field, and IV fluids are
simply infused and adjusted based on hemodynamic
response. For a burn-injured child, as with any
pediatric trauma patient, a 20-cc's/kg fluid bolus
should be administered, by which point one hopes the
patient will be at the emergency department [1]. In
adults with severe bums, the Advanced Burn Life
Support (ABLS) course recommends that adults
receive a 500-cc's fluid bolus, although many centers
recommend that EMS personnel simply administer
wide-open fluids because it is difficult to give the
severely burned adult

Box 5. Consensus/Parkland formula for

estimating fluid requirements for the first 24
hours postburn [1]
4 cc's/kg/BSA burn
4 cc's of lactated Ringers or 0.9
normal saline
Big kid versus little kid (kg)
Bad burn versus not bad burn (
BSA burn)
One half of total amount administered over
first 8 hours after burn (not timed from
arrival in emergency department)
Remaining one half of fluids administered
over next 16 hours
Remember: This formula is only a guide.
This formula is based on the assumptions that
urine output is adequate and the patient is not
in shock. Fluid requirements may be greater in
these conditions.

S. DeBoer, A. O'Connor / Crit Care Nurs Clin N Am 16 (2004) 6173

patient enough fluids in the prehospital setting. In

areas with prolonged prehospital transport times, these
guides must certainly be adapted. Accurate estimation
of the volume of fluid given during transport by EMS
is then figured into the total sum of fluids that the bum
patient should receive according to the consensus
formula [2,4,11].
Urine output

Urine output should be measured in the emergency

department to assess fluid requirements better. Two
categories of patients should have urinary catheters
placed before transport to a bum center. First are those
with burns to the genitalia. Burns in this area can
cause extensive edema, and if a catheter is not placed
early in the resuscitation, later transurethral insertion
may be impossible, requiring placement of a
suprapubic catheter. The second category of patients
requiring urinary catheterization is patients with
serious burns (> 10% TBSA) requiring hospitalization
and extensive fluid resuscitation. The accepting burn
center can also provide guidance if referring staff are
unsure whether a urinary catheter should be placed [1,
11].
A major concern in the emergency department and
later burn center settings is to prevent or treat
myoglobinuria. If the Foley bag contains very dark
urine ("Pepsi pee"), significant myoglobinuria is
present. When extensive muscle damage occurs (eg, in
electrical burns), myoglobin is released and flows
through the blood stream to the kidneys, potentially
clogging the tubules and resulting in kidney damage or
failure. If significant myoglobinuria is grossly visible
or found to be.present by urinalysis, the treatment is
simply to increase hourly fluid ad-ministration to flush
the kidneys. Other concurrent therapies, such as
administration of a diuretic such as mannitol or
alkalization of urine by administering sodium
bicarbonate, can be recommended by the burn center [
5,11].
Temperature

Hypothermia can quickly ensue because of the

physical loss of skin, environmental factors such as
cold, wet clothing, and ambulance and emergency
department ambient temperatures. In addition to maintaining a warm environment, one should remember
that wet skin gets colder 30 times faster than dry skin [
1,14]. Hypothermia can compromise perfusion and the
hemodynamic stability of the patient. Hypothermia
may result in prolonged clotting times, hemodynamic
instability, and even apnea in infants and

69

children. Infants and small children lose significant

amounts of heat from their large heads, so a small
stocking cap can be made from stockinet or other
material and applied to the head in an attempt to
minimize heat loss. If available, warmed IV fluids
should be used, because fluids at room temperature (
68F) can quickly result in disastrous hypothermia.
Interventions such as keeping the ambulance or treatment room as warm as tolerable and using a convection forced-air warmer (Bair Hugger, Arizant Health
Care, Eden Prarie, MN) or warming blankets can help
prevent heat loss in these patients [1,14].
EMS and emergency department wound care

In the prehospital and emergency department

environments, the priorities of major burn management are to stop the burning process, address the
ABCs, provide analgesia, cover the wound with dressings, and transport the patient. For transport, serious
bums should be loosely covered with dry or Water Jel
(Water Jel Medical Technologies, Carlstadt, NJ)
dressings, per burn center preference. Clean (sterile if
available), dry sheets should be placed under and over
the patient, with a blanket to prevent heat loss (even in
summer). Silver sulfadiazine (Silvadene) although
commonly used for burns in the outpatient and inpatient settings, should not be placed on the burn if the
patient is being transferred to another facility, because
the receiving staff will have to remove the dressings
and the silver sulfadiazine to assess the burn [2,11].
Small bums can be covered initially with gauze and
saline or Water Jel. As described earlier, although wet
dressings feel better, they can result in a worsening of
hypothermia. Wounds in patients with minor burn
injuries who may be sent home or admitted to a
hospital facility (but not transferred to a burn center)
should be lightly covered with topical antimicrobial
agents such as silver sulfadiazine or neomycin and
gently wrapped with dry gauze or synthetic occlusive
dressings such as Biobrane (Bertek Pharmaceuticals,
Morgantown, West Virginia), DuoDerm (ConvaTec,
Princeton, New Jersey), or Opsite (Smith & Nephew,
Largo, Florida) [1,2,11]. Repeated assessments and
dressing changes can then be accomplished at home by
the patient or family members, in the office by the
primary physician, or in the outpatient hospital
settings.
There are three schools of thought regarding burn
blisters. Some believe the blister should be left intact
because the top layer acts as a biologic barrier to
infection. Some centers aspirate blister fluid with a
syringe, because the fluid is thought to impair leukocyte activity, but leave the blister covering intact.

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S. DeBoer, A. O'Connor / Crit Care Nurs Clin N Am 16 (2004) 6173

Some centers advocate the complete removal of all

blister fluid and the epithelial covering because of
concerns about impaired wound healing [11]. Whatever method of blister management is chosen, the
wound should be covered with a topical antimicrobial
agent (if the patient is not going to be transferred) and
close follow-up ensured [2,11].
In the emergency department setting, if the patient
is to be discharged home or admitted, gentle cleansing
with warm water and mild soap is appropriate. Again,
if the patient is going to be transferred to a bum center,
clean and dry dressings (or Water Jel, per bum center
preference) are appropriate; the burn center will later
clean the wounds with the agents of its choice. Last,
both in pediatric and adult burn patients, immunization
status should be assessed, and subsequent tetanus
prophylaxis should be administered as needed [2].
Pain management
The wise person looks not for pleasure, but merely
freedom from pain (Aristotle 384-322 BCE)
Disease can destroy the body, but pain can destroy the
soul (E. Lisson 1989)

Bum pain is unlike any other pain and can require

amounts of analgesia that in other patients would be
considered unsafe. With minor superficial burns,
topical anesthetics (Solarcaine, aloe vera) or oral
medications, such as acetaminophen with or with-out
codeine or ibuprofen, can often provide accept-able
pain relief. Topical anesthetics should be used with
caution in children with larger body surface areas,
because absorption of the anesthetic may cause
seizures.
IV analgesia should be used with more severe
burns. IV morphine or fentanyl can be used for
systemic analgesia in conjunction with aggressive
fluid resuscitation [5,11,14]. If the patient is in shock,
blood is preferentially shunted to the heart, lungs, and
brain. Therefore, administration of intramuscular or
oral medications is not advisable in these patients.
Nurses should serve as patient advocates in assuring
adequate pain relief for all patients [5]. Sufficient
medication should be given to keep the patient calm,
conscious, or at least easily awakened. A bag-valvemask device with oxygen and an appropriate-sized
mask should be always kept at the bedside in case of
severe respiratory depression. In pediatric patients 0.1
mg/kg IV morphine and in adults 5 to 10 mg IV
morphine every 5 minutes may be necessary to
provide adequate pain relief [2]. These amounts are in
stark contrast with the 1 to 2 mg IV of morphine that

is cautiously administered to adult patients with chest

pain. If necessary, naloxone (Narcan) can be used to
reverse opiate-induced respiratory depression. Paramedics with adult overdose patients teach the concept
of "B without B""breathing without beatings!"
Administration of naloxone can result in excruciating
pain as the naloxone reverses the analgesic agent. The
same is true for opiate-induced respiratory depression
in burn patients. Small, repeated doses (0.1 mg/kg in
children under 12 months of age and 1.0 mg in older
children and adults) of IV naloxone should be
administered for respiratory depression or apnea, in
addition to assisted ventilation as needed [15]. If the
patient who has received appropriate amounts of
analgesics and finally is comfort-able also stops
breathing, intubation to allow adequate pain control
should be seriously considered.
A relatively new innovation in pediatric burn pain
management in the hospital setting is the fentanyl
Oralet (Abbott Laboratories, Abbott Park, Illinois).
Fentanyl is a synthetic opiate that is 100 times more
powerful than morphine and, in addition to the commonly administered IV route, can also be given in
orally, as an Oralet or in lollipop form. This option
works well if IV access is not in place; the major
drawback is a 30% incidence of nausea or vomiting,
especially in the opiate-naive patient. For treatment of
pain in children during dressing changes, the University of Chicago Bum Center has had good success with
this medication because it provides pain relief and
moderate sedation, but only for short periods of time;
the half-life of fentanyl is much shorter than that of
morphine [16]. With any bum, regardless of severity,
the importance of parental or family support cannot be
overstated. Calming measures from the family members
and distraction therapies such as music or videos can
reduce anxiety and pain in the child, which in turn
reduces the pain and anxiety felt by the emergency
department staff caring for the pediatric burn patient [
14].
Fasciotomies and escharotomies
A full-thickness circumferential burn, that is, a bum
that goes all the way around a body part, can impair
circulation because of excessive pressure within the
tissue compartment. When the entire thorax is involved,
respiration can be impaired. Compartment compression
is the result of the inflexibility of the eschar (dead
tissue), which does not stretch, to accommodate the
rapid progression of swelling. Circulatory, motor, and
sensory functions may be compromised as edema
compresses the veins, nerves, and arteries. In the
emergency department setting, in

S. DeBoer, A. O'Connor / Crit Care Nurs Clin N Am 16 (2004) 6173

patients with circumferential burns, extremity escharotomies or fasciotomies are rarely needed if expedient
transport to a burn center can be arranged, unless
neurovascular compromise is present. If the chest is
circumferentially burned, and ventilation cannot occur
despite mechanical ventilation with an endotracheal
tube, a chest escharotomy may be indicated before
transport to a burn center [2,11].
In summary, EMS and emergency department
personnel provide essential assessment and management of the burn-injured patient through aggressive
fluid resuscitation, airway and pain management,
application of burn wound dressings, and treatment of
compartment compression requiring escharotomies.
Frequent contact with the receiving burn center is
essential for guidance, support, and optimization of
patient survival.
Overview of special burns
Electrical injuries

For prehospital caregivers, the first priority before

assessing and managing any patient is always scene
safety. Three differences must be remembered when
confronted with a high-voltage (> 5001000 volts) or
low-voltage (< 5001000 volts) electrical burn injury.
First, electricity follows nerves and fluid. Nerves are
attached to muscles and contract when stimulated,
possibly resulting in spinal injuries caused by the
muscular contraction or subsequent falls from a height.
Therefore, in these patients spinal injury precautions
involving rigid cervical collars and spinal boards are
appropriate in the prehospital setting, until physical
examination or radiography rule out a spinal cord
injury [1,1719]. Second, the on-site caregiver should
remember, "Electricity loves nerves." Nerves are
located deeper in the tissues, so electrical burns cause
thermal injury from deep tissue progressing outward.
Electrical burns are otherwise characterized by
statements such as "what you see on the outside is not
always what's on the inside" or the "tip of the iceberg
syndrome." The visible burns may not appear severe,
but the internal injuries can be more severe because of
the thermal damage to deep tissues as the electricity
moved through the body. In toddlers, the most common
type of electrical burn is a mouth burn from chewing
on electrical cords. Though these burns can initially
seem minimal, the real risk with this injury comes 3 to
5 days after the burn, when delayed hemorrhage from
the labial artery can occur [1]. Fluid resuscitation
formulas may not be accurate, because internal thermal
damage is not easily assessed; thus, with electrical
burns, fluids are given to achieve hemodynamic
stability and urine output of

71

at least 1 cc/kg/hour in children and 100 cc/hour in

adults [1,17]. Third, one must consider electricity's
effect on major muscle groups, and the much higher
risk for associated myoglobinuria, and admitting all
patients sustaining high-voltage burns for at least 24
hours of cardiac enzyme and ECG monitoring for
potentially lethal arrhythmias [1,2,17].
Lightning injuries

The amount of energy that accompanies a lightning

strike can be beyond the imagination. Only 110 to 220
volts is encountered with biting through an electrical
cord or putting a finger or a fork in a socket. If a
person grasps a power line, several thousand volts can
be involved. Lightning has been measured ranging
from 2000 to 2 billion volts, an unimaginable amount
of energy [20]. The same concerns apply to lightning
injuries as to any electrical burn. Spinal injuries may
occur from muscle contractions, from being thrown, or
from blunt or penetrating trauma from nearby debris.
The most common cause of death in lightning victims
is cardiac arrest caused by a massive countershock to
the myocardium and paralysis of the medullary
respiratory center [20]. Almost all victims of lightning
strikes who do not suffer cardiac arrest do survive, but
long-term cardiac, neurologic, and ophthalmologic
sequelae are common [20]. Because of the short
duration of the lightning exposure, the current tends to
flash over the body with resulting deep entrance and
exit wounds; myoglobinuria rarely occurs. Patients
struck by lightning should be admitted for at least 24 to
36 hours of observation and continuous cardiac
monitoring, with follow-up cardiac, neurologic, and
ophthalmologic examinations [17,20].
Chemical burns

Treatment of chemical burns, whatever the chemical, essentially consists of flushing the skin with
copious amounts of water. The only notable exceptions to this rule are burns from alkali metals such as
sodium, potassium, and lithium. These metals burn and
can even explode when placed in contact with water
and therefore should be covered in oil and then
carefully removed. There are specific antidotes for
certain chemical exposures, such as hydrofluoric acid
and white phosphorous, but they are exceptions to the
rule. If the patient has a chemical burn, flush the skin
with water first, then consider finding and administering the antidotes [2].
Hot tar burns

Tar is sticky and hot. Tar is heated to 120C to

135C (275300F) for paving roads and to 218C to

72

S.

DeBoer, A. O'Connor / Crit Care Nuns Clin N Am 16 (2004) 6173

245C (450F500F) for roofing projects. The pri-

ority for EMS and emergency department personnel is

not to get the tar off but to cool the tar down. Wellmeaning health care workers focus on trying to get the tar
off, while thermal energy from the tar continues to
penetrate the underlying tissue. Copious amounts of cool
water or Water Jel dressings should be used to cool the
tar. Signs and symptoms of hypothermia need to be
assessed during the cooling of the tar. Once the tar is
cooled, it can be removed. Emollient ointments such as
petroleum jelly, neosporin, or even mayonnaise will help
separate the tar from the skin and make removal easier.
Once the tar is removed, the depth of the tissue injury
can be assessed [2].
Nonaccidental burns

If the reported mechanism of injury does not fit the

injury, abuse is assumed until proven otherwise. Whether
based on conflicting or changing history or on suspicious
findings, the possibility of abuse must be entertained with
bum-injured children and elderly persons. If the injury is
thought to have been caused by abuse, it must be
reported to the appropriate authorities, because of legal
mandates and because of the associated ethical
implications. EMS personnel should inform the
emergency department of their suspicions and document
the initial on-scene findings, verbal history, and findings
from the physical assessment of the patient. Whether the
child is going to be discharged home, admitted, or
transferred to a burn center, the ER should call and
report their suspicions of abuse. Even if the burn center
will also call, it is recommended that both the transferring
and the receiving centers notify the appropriate contacts.
Health care providers have an obligation to help protect
those who cannot protect themselves [1,7].
Prehospital and emergency burn care priorities can be
summarized as assessment of the ABCs and
transportation of the patient to an ABA burn center for
definitive treatment. The primary survey focuses on the
mechanism of bum injury, assessment of associated
trauma, establishment of a patent airway, and initiation of
fluid resuscitation. The secondary survey expands the
primary survey to include aggressive pain management
and initial bum treatment. EMS and emergency
department personnel who are knowledgeable about bum
patient resuscitation and management can improve
patient survival.
Acknowledgment
The authors thank Dr. Lawrence Gottlieb of the
University of the Chicago Bum Center and Dr. Ma

delyn Kahana of the University of Chicago Pediatric

ICU for their ongoing support of prehospital and
emergency bum education.

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